Citation NR: 9734178
Decision Date: 10/08/97 Archive Date: 10/16/97
DOCKET NO. 95-31 836 ) DATE
)
)
On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) in
Wilmington, Delaware
THE ISSUE
Entitlement to service connection for a left shoulder
disorder
REPRESENTATION
Appellant represented by: Vietnam Veterans of America
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
J. Horrigan, Counsel
INTRODUCTION
The veteran served on active duty from May 1970 to April
1991.
This matter comes before the Board of Veterans’ Appeals
(Board) from a June 1994 rating decision of the RO denying
service connection for a left shoulder disability. In June
1997, the veteran appeared and gave testimony at a hearing
before the undersigned Board member at the RO, a transcript
of which is of record.
In an August 1994 rating decision, the RO denied service
connection for a respiratory disorder. The veteran filed a
notice of disagreement from this rating decision in February
1995, but has not been provided a statement of the case in
regard to this issue. It is referred to the RO for
appropriate action. Only the issue listed on the title page
of this decision is before the Board for appellate
consideration at this time.
CONTENTIONS OF APPELLANT ON APPEAL
It is contended, by and on behalf of the veteran, that he
incurred chronic left shoulder disability due to injuries
sustained on active duty
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1997), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file(s). Based on its review of the relevant evidence
in this matter, and for the following reasons and bases, it
is the decision of the Board that the evidence supports a
grant of service connection for a left shoulder disorder.
FINDING OF FACT
The veteran has a left shoulder disorder which developed
during service.
CONCLUSION OF LAW
A left shoulder disorder was incurred during service. 38
U.S.C.A.§§ 1110, 1131, 5107(West 1991 & Supp 1997).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The Board notes initially that the appellant’s claim for
service connection for a left shoulder disorder is “well
grounded” within the meaning of 38 U.S.C.A.§ 5107(a). That
is, the Board finds that this claim is plausible. All
relevant facts pertaining to the claim have been developed to
the extent possible and no further assistance to the veteran
is required in order to satisfy the VA's duty to assist him
in the development of this claim as mandated by 38 U.S.C.A.
§ 5107(a).
On the veteran’s February 1970 examination prior to entrance
onto active duty, his upper extremities were evaluated as
normal. Review of the service medical records reveals that
the veteran was seen in December 1986 with complaints of left
shoulder pain of 11 months duration. He reported that there
was stiffness in the shoulder in the morning which worked out
during the day. On evaluation, fair range of motion, except
for external rotation, was noted. Crepitus was reported as
was tenderness to palpation. An X-ray showed no fractures,
dislocations or soft tissue calcification. The osseous
structures appeared to be intact. The assessment was
probable shoulder joint arthritis. When seen later that that
month, it was noted that there was normal active range of
motion with no pain except on abduction. The provisional
diagnosis was probable tendonitis. There were further
complaints of left shoulder pain in January1987 and February
1987. Assessmants included residual left shoulder
tendonitis.
In January 1988, the veteran was seen after he injured his
left shoulder when he fell off a truck. It was noted that he
landed right on the point of the shoulder. He pointed to the
left posterior scapula as the area that hurt. Slight
bruising was present. Palpation of the clavicle and acromion
produced minimal tenderness. An X-ray revealed no fracture
or subluxation. The assessment was contusion of the left
shoulder. When seen again two days later, it was noted that
the veteran was taking Motrin. Mild-moderate residual
tenderness was noted. There was full range of motion with
some tenderness at the extremes. Resolving ecchymosis with a
central abrasion was noted over the superior aspect of the
scapula. The assessment was resolving contusion of the left
shoulder.
The veteran was again seen in January 1989 with complaints of
left lateral chest and left shoulder pain of 2-3 hours
duration. The assessments included R/O myocardial infarction
, atypical chest pain, angina, or stress. The following
month it was noted that the veteran had been hospitalized
earlier to rule out a myocardial infarction and that his
enzymes were negative. The veteran was noted to give a
history of a left shoulder injury with recurrent pain.
Tenderness was noted below the acromioclavicular joint.
There was pain with resisted pronation and with abduction.
When seen later in February 1989, it was noted that the
veteran’s chest and shoulder pain appeared to be
musculoskeletal. The veteran’s examination prior to
separation from service is not of record.
On VA examination in September 1993, the veteran gave a
history of shoulder strains incurred when he fell backwards
with an air bottle on his back while evacuating people from a
plane in 1986. He was treated for about a month and most of
his shoulder motion was restored, although he continued to
have trouble with the shoulders thereafter. Physical
examination revealed tenderness of the shoulders with
decreased strength on external rotation X-rays were normal.
The diagnoses included old rotator cuff injuries with some
residual weakness-service connected.
An undated clinical record from a service medical facility
revealed that the veteran received a cortisone injection in a
left shoulder and deltoid muscle trigger point.
In a June 1997 statement, G. Mitchell Edmondson, M.D.,
reported treating the veteran from September 1996 for
complaints which included shoulder pain. The doctor believed
that the veteran suffered from degenerative arthritis due to
work related trauma.
During a June 1997 Board hearing at the RO, the veteran said
that he injured his left shoulder during service when he
stepped backward off a firetruck and fell on the shoulder.
He strained his shoulder earlier during service while
rescuing people from an aircraft. On that occasion he
received treatment for about 6 weeks. After service he
received treatment from private physicians for left shoulder
pain and stiffness and his physician diagnosed arthritis due
to trauma.
Under the applicable criteria, in order to establish service
connection for disability, there must be objective evidence
that establishes that such disability was either incurred in
or aggravated by service. 38 U.S.C.A. §§ 1110, 1131.
The service medical records indicate considerable treatment
for left shoulder pain, stiffness, and limitation of shoulder
motion, including symptoms resulting from an injury to the
shoulder incurred when the veteran fell off of a truck. The
assessments rendered during service included probable
arthritis, tendonitis, and a contusion to the left shoulder.
After a VA examination conducted in September 1993, the VA
examining physician diagnosed the veteran as having old
rotator cuff injuries with some residual weakness. The
physician opined that this disability was service connected.
In June 1997, a private physician diagnosed the veteran as
having degenerative arthritis due to work related trauma.
Given the considerable treatment during service for left
shoulder complaints, the post service medical evidence of
continuing left shoulder disability, and the opinion of a VA
physician that the veteran’s left shoulder disability is
related to service, service connection for the veteran’s left
shoulder disorder is warranted.
ORDER
Service connection for a left shoulder disorder is granted.
BRUCE E. HYMAN
Member, Board of Veterans' Appeals
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
1991 & Supp. 1997), a decision of the Board of Veterans'
Appeals granting less than the complete benefit, or benefits,
sought on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act,
Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The
date which appears on the face of this decision constitutes
the date of mailing and the copy of this decision which you
have received is your notice of the action taken on your
appeal by the Board of Veterans' Appeals.
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